The commissioner, Dr. Shereef Elnahal, said in an interview that the Wanaque Center for Nursing and Rehabilitation did not have enough room to isolate the children when they became ill in the facility's ventilator unit. Nineteen children have been sickened by the virus, including one on Thursday.

All of the children were on ventilators and had compromised immune systems, making any effort to quarantine them all but impossible, Elnahal said. "There was not a place [at the center] where they could have been safely placed," he said.

The cause of the outbreak and how the virus spread so quickly among the children remains unknown, Elnahal said.

"I’ve seen respiratory outbreaks before but I have not seen it in such a vulnerable group of patients," said Elnahal, who previously worked for the federal Department of Veterans Affairs. "This is the worst [kind of] facility where this could have occurred, even if you have a facility that’s doing everything it can to prevent it."

He would not say how critical the 12 sick children are or whether any have fully recovered.

New Jersey Department of Health Commissioner Dr. Shereef Elnahal speaks about the adenovirus outbreak during a press conference at the The Wanaque Center for Nursing and Rehabilitation on Wednesday, October 24, 2018. New Jersey Governor Phil Murphyl looks on. (Photo: Michael Karas/NorthJersey.com)

A team of investigators and monitors from the Health Department remained on site Thursday at the center, which sits off Ringwood Avenue in the Haskell section of Wanaque. The facility has been barred from admitting new patients until the outbreak is declared to be over, which will likely be a minimum of four weeks, Elnahal said.

Representatives for the center did not address several questions concerning:

Criticism from unions representing nurses and other workers over "worsening staffing levels, lack of adequate supplies, and severe cutbacks to job standards."

The center's private, for-profit owner, Wanaque Nursing & Rehabilitation, has retained a Philadelphia-based public relations agency to field questions about the outbreak. The agency on Thursday issued a statement from the center's administrator, Rowena Bautista, expressing sympathy for the families of those who died. She said they are offering grief counseling to staff members, patients and families.

"We are working side-by-side with medical experts from the Department of Health and the CDC, and will be in constant contact with them until this issue is fully resolved," the statement read, referring to the federal Centers for Disease Control and Prevention.

Elnahal said Health Department investigators have not found any violations of staffing levels at the center.

On Thursday, health officials announced that a 19th child had been sickened from exposure to adenovirus — a common virus that causes mild illnesses like colds and coughs in healthy people but can be deadly to those with weakened immune systems.

The child had been ill before Monday, which is when the last child had been stricken with the virus, state officials said. The diagnosis was confirmed by a laboratory on Thursday. Children with confirmed cases became ill between Sept. 26 and Monday.

New Jersey Governor Phil Murphy speaks about the adenovirus outbreak during a press conference at The Wanaque Center for Nursing and Rehabilitation on Wednesday, October 24, 2018. (right) New Jersey Department of Health Commissioner Dr. Shereef Elnahal. (left) New Jersey State Epidemiologist Dr. Christina Tan. (Photo: Michael Karas/NorthJersey.com)

The outbreak has been confined to the ventilator unit at the center, which holds patients who need mechanical support to breathe.

As of Wednesday, the Wanaque Center had 49 children in the ventilator unit, which is licensed for 72 children, health officials said. An additional 20 beds are available for older children in another area, she said.

The first case of a patient with the adenovirus was noted on Sept. 26. The Health Department was notified of a "cluster of respiratory illnesses" at the center on Oct. 9, after the office closed for the day. Health officials began surveillance work at the facility the next morning.

State officials did not give specific dates for the deaths except for the seventh victim, who died Tuesday night.

Health officials conducted a surprise inspection over the weekend, during which they found "minor handwashing deficiencies," the Health Department said in a statement.

The facility has been cited in annual government inspection reports from 2015 to 2018 for instances of poor patient care and unsanitary practices that could spread infection.

Elnahal described the most recent citations in August as "low level" violations that would not pose a risk to patients. He said they were corrected by the time the department conducted the surprise inspection on Sunday.

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